Practice review: Evidence-based and effective management of pain in patients with advanced cancer.

BACKGROUND: Pain of a moderate or severe intensity affects over half of patients with advanced cancer and remains undertreated in at least one-third of these patients. AIM: The aim of this study was to provide a pragmatic overview of the evidence supporting the use of interventions in pain management in advanced cancer and to identify where encouraging preliminary results are demonstrated but further research is required. DESIGN: A scoping review approach was used to examine the evidence supporting the use of guideline-recommended interventions in pain management practice. DATA SOURCES: National or international guidelines were selected if they described pain management in adult cancer patients and were written within the last 5 years in English. The Cochrane Database of Systematic Reviews (January 2014 to January 2019) was searched for 'cancer' AND 'pain' in the title, abstract or keywords. A MEDLINE search was also made. RESULTS: A strong opioid remains the drug of choice for treating moderate or severe pain. Bisphosphonates and radiotherapy are also effective for cancer-related bone pain. Optimal management requires a tailored approach, support for self-management and review of treatment outcomes. There is likely a role for non-pharmacological approaches. Paracetamol should not be used in patients taking a strong opioid to treat pain. Cannabis-based medicines are not recommended. Weak opioids, ketamine and lidocaine are indicated in specific situations only. CONCLUSION: Interventions commonly recommended by guidelines are not always supported by a robust evidence base. Research is required to evaluate the efficacy of non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, complementary therapies and transcutaneous electrical nerve stimulation.

What influences patients' decisions on artificial hydration at the end of life? A Q-methodology study.

CONTEXT: Artificial hydration (AH) is used to palliate patients with reduced fluid intake at the end of life but is a controversial practice. Patients' involvement in decision making varies, and little is known about patients' understanding of the benefits and burdens of AH. OBJECTIVES: To identify the factors that patients consider most important when making decisions regarding AH at the end of life. METHODS: Interview study using Q-sort methodology conducted with 20 patients with advanced diseases recruited from inpatient and outpatient palliative care services. RESULTS: Several domains appear to influence a decision about AH: the patient's understanding of AH, their philosophical position on end-of-life care, the process of discussion, and who makes the final decision. Patients generally based their decision on whether AH would improve quality of life, although prolonging life was important for some. Hydration was not considered a burden, and many would want a trial of AH in the event that they could no longer drink. Patients wanted to be guided by medical opinion, although some wanted to make the decision on their own. All patients welcomed the opportunity to discuss AH. CONCLUSION: Patients view AH as an important issue and are keen to be involved in decision making. Health care professionals may withhold AH at the end of life because they perceive it as a burden on patients and on their interactions with family, although this view is not shared by patients. Some patients lack understanding regarding the likely benefits of AH. Research examining the impact of clinical information regarding AH on patients' decision making is now needed.